Flexible ovarian stimulation in a poor responder: a case report and literature review

This article reports on a novel strategy of continuous ovarian stimulation in a poor responder with two oocyte retrievals within the follicular and luteal phases of the same menstrual cycle. It also reviews studies of flexible ovarian stimulation. A patient aged 41 years diagnosed as infertile with low ovarian reserve sought IVF treatment. A minimal ovarian simulation protocol was commenced with use of low-dose urinary FSH (150IU/day) from day 3, combined with using clomiphene citrate (50-100mg) when the biggest follicle reached 10mm in diameter to prevent ovulation. Gonadotrophin-releasing hormone agonist was administered on day 15 when the lead follicles reached 18 mm in diameter. The first ultrasound-guided oocyte retrieval was performed 21 h later; however, no ovum was obtained. Luteal-phase ovarian stimulation was started 2 days later. The second oocyte retrieval was performed 25 h after human chorionic gonadotrophin administration. Finally, one mature oocyte resulting in a cleavage embryo (8-cell, grade 2) was obtained. The case demonstrates that it is feasible to obtain mature oocytes and good embryos from luteal-phase stimulation. Continuous stimulation during the follicular and luteal phase can be a solution for poor ovarian response. Ovarian stimulation may be performed flexibly in special circumstances. This article reports on a novel strategy of continuous ovarian stimulation on a poor responder during the follicular and luteal phases of the same menstrual cycle with two oocyte retrievals. It also reviews studies of flexible ovarian stimulation. In our case, a patient, aged 41, who was diagnosed as infertile with very poor ovarian function, sought therapy for IVF. Antral follicles and basic hormones were evaluated on day 2 of the menstrual cycle. The stimulation cycle was commenced with use of 150IU/day urinary FSH from day 3, combined with clomiphene citrate and ibuprofen in the late follicular and luteal phases to prevent ovulation. Oocyte retrieval was attempted twice. We performed luteal-phase ovarian stimulation continuously 2 days after the first failed oocyte retrieval during the follicular phase. Finally, one mature oocyte resulting in a cleavage embryo (8-cell, grade 2) was obtained after the luteal phase stimulation and retrieval, redeeming the previous unsuccessful oocyte retrieval. The case demonstrates that it is practical to obtain mature oocytes and good embryos from maintaining luteal-phase stimulation. For poor ovarian response, continuous stimulation during the follicular and luteal phases can be a solution. The literature review summarizes the clinical outcomes and parameters of flexible ovarian stimulation previously reported, including luteal-phase oocyte retrieval plus in-vitro maturation, ovarian stimulation initiated during the follicular or luteal phase and random-start stimulation. With knowledge gleaned from the case and review of studies, ovarian stimulation may be performed flexibly in special circumstances.